Wound Management and Care

Question 1

This initiates wound healing. Its function is to limit tissue damage, remove injured or damaged cells, and repair the injured tissue.This is the body’s initial local defense response to injury or trauma, and it begins immediately after injury ortrauma.

Answer 1

Inflammatory Phase

Question 2

What are the three stages of Inflammatory phases?

Answer 2

Vascular, Exudate, Reparative

Question 3

What is the vascular stage?

Inflammatory Phase

Answer 3

• Characterized by hyperemia due to change in cellular filtration pressures and an increase in the permeability ofcells.
• Produce local edema, warmth, erythema, and discomfort, which are the cardinal signs and symptoms of inflammation.

Question 4

What is the exudate stage?

Inflammatory Phase

Answer 4

• Several appearances seen in the wound; serous, purulent, fibrinous orhemorrhagic.
• A fluid passes through the walls of vessels into adjacent tissues or spaces to help deposit fibrins and leukocytes, which are necessary to initiate wound healing.

Question 5

What is the reparative stage?

Inflammatory Phase

Answer 5

Damaged cells are replaced and true wound healing begins. Damaged cells are removed through phagocytosis, which is accomplished by polymorphonuclear cells andmonocytes.

Question 6

1.1.Measure the longest and widest
1.2.Portions of the wound
1.3.Use disposable, plastic
1.4.Cover/overlay to measure the wound and the measurement should be in centimeters
1.5.The plastic overlay should be positioned on the wound so its top is directed towards the patient’s head
1.6.Length measurements are made along a line from 12 o’clock (head) to 6 o’clock(foot)
1.7.Width measurements are made from 9 o’clock (left) to 3 o’clock(right)

Answer 6

To assess a wound size:

Measurements in cm
Top of overlay directed towards the patient’s head
Length = 12 o’clock (head) to 6 o’clocl (foot)
Width = left to right

Question 7

2.1.Insert the sterile cotton tipped swab
2.2.Vertically into the wound until it contacts the bottom or floor of the wound.
2.3.Use thefinger , thumbnail,or maker to indicate where the upper portion of the shaft of the swab exits the wound.
2.4.Measure the distance of the top and end of the swab

Answer 7

To assess wound depth:

use sterile cotton tipped swab
vertical until contacts bottom
Use finger, thumbnail, or marker to mark where the swab exits the wound
Measure distance of top to end

Question 8

3.1.Insert the swab horizontally until it contacts to the bottom or floor of thewound
3.2.Use the finger, thumbnail, or maker to indicate where the upper portion of the shaft of the swab exits the wound.
3.3.Using the clock method, the area of tunneling should beidentified

Answer 8

To assess wound undermining:

Question 9

proccess of granulation

color patterns wounds

Answer 9

Red

Question 10

What color is an eschar?

color patterns of wounds

necrotic tissue that may be either soft or hard
MUST debride

Answer 10

Black

Question 10

What color/s is a slough?

color patterns of wounds

has a stringy or mucinous consistency; consists of WBCs, bacteria, and degraded extracellular matrix
Debride necrotic tissue
Absorb drainage
Protect periwound

Answer 10

Yellow or grayish brown

Question 11

Coverage of the wound by new skin is occuring

color patterns of the wound

Protect this wound
Maintain warm, moist environment
Protect periwound

Answer 11

Pink and shiny

Question 12

• Removal of necrotic tissue from the wound that allows it to heal more effectively.
• Can be performed with sharp instruments

Answer 12

Debridement

Question 13

Done with the use of scalpel or scissors to remove thick adherent eschar and other devitalized tissue. This is the most rapid method. Performed when there is >70% necrotictissue.

Answer 13

Sharp Debridement

Question 14

can be performed through pressure irrigation, removal of dressings, hydrotherapy, electricalstimulation, acombination of hydrotherapy and ultrasonography, and the use ofdextranomers.

Answer 14

Mechanical Debridement

Question 15

can be performed through enzymatic debridement with exogenous agents such as collagenase which is applied to thewound.

Answer 15

Chemical Debridement

Question 16

the use of self-produced exogenous enzymes performed with a very occlusivedressing.

Answer 16

Autolytic Debridement

Question 17

2.1.Care of the wound usually requires the selection and application of one ormoretypes of dressings.
2.2.To protect the wound, assist the healing process, reduce infection or contamination of the wound, and remove exudates and toxic waste when the dressing is removed.
2.3.Can be used to add moisture in very dry wounds or to remove and absorb moisture in wounds with large amounts ofexudate.

Answer 17

Dressings

Question 18

• Placed against a wound while clinician traces the wound
• Tracing is affixed within the pt’s medical record
• Measuring of length, width and depth is the same as direct measurement

Answer 18

Wound Tracings

Question 19

narrow passageway created by the separation of, or destruction to, fascialplanes; common in neuropathic ulcers and surgical wounds

Answer 19

Tunneling

Question 20

occurs when the tissue under the wound edges becomes eroded, resulting in a large wound with a small opening; commonly found in pressure or neuropathic ulcers

Answer 20

Undermining

Question 21

Temporary scaffolding of vascularized connective tissue that fills the wound void

Wound Bed

Healthy: beefy red appearance (dt presence of oxygen-rich capillaries)
Poor blood supply: pale or dusky in color (will heal more slowly than wounds with healthy granulation tissue)

Answer 21

Granulation tissue

Question 22

Dead, devitalized tissue adhered to the wound bed; impedes healing and promotes infection

Answer 22

Necrotic tissue

Question 23

Refers to the tissue at the perimeter of the wound

Answer 23

Wound Edges

Question 24

Assess and document the type, color, consistency and amount of wound drainage or exudate

Answer 24

Wound Drainage

Question 25

tissue surrounding the wound

Answer 25

Periwound

Question 26

Ulcers caused by a decrease in arterial blood supply

Commonly found: Distal toes, Dorsal Foot, Lateral Malleolus

Answer 26

Arterial insufficiency ulcer

Question 27

Ulcers due to vein dysfunction (dilated vein/ incompetent calves), calf muscle pump failure, or a combination of the two

Commonly found: Medial aspect of the lower leg, Medial malleolus

Answer 27

Venous insufficiency ulcer

Question 28

Aka diabetic ulcerationsUlcers due to hyperglycemia -> damage the small blood vessels supplying the nerves; due topoor blood supply on the nerves, sensory function of the nerves are impaired (neuropathy)

Commonly found: Weight bearing surfaces of the foot:
Plantar aspect of the foot
Areas of increased plantar pressures or shear forces such as under the metatarsal heads

Answer 28

Neuropathic ulcer

Question 29

If the affected area of the foot has decreased or absent pulses, skin is cool or cold to touche, and severe pain due to tissue ischemia, what is the ulcer?

Answer 29

Arterial Insufficiency Ulcer

Question 30

Affected area is the medial malleolus and there are (N) pulses as well as (N) to wild warmth skin temperature. Pain is mild to moderate and the pt c/o heaviness of the involved limb. What is the Ulcer?

Answer 30

Venous Insufficiency Ulcer

Question 31

The wounds for this ulcer commonly presents as round, punched out lesions with a characteristic rim of callous and minimal drainage. What is the Ulcer?

Answer 31

Neuropathic Ulcer

Question 32

Tissue is necortic, has foreign material, debris, residual topical agents, blisters, and callus. Debride or not?

Answer 32

Debride

Question 33

Tissue is granular and viable, stable heel ulcers, electrical burns, and deeper tissues. Debride or not?

Answer 33

Do not debride

Question 34

Most readily available wound dressing

Answer 34

Gauze

Question 35

• Thin, flexible sheets of transparent polyurethane with an adhesive backing
• Resists shear, self-adherent and allows visualization of the wound bed

Answer 35

Transparent Film Dressing

Question 36

• Made of polyurethane with a hydrophilic wound side and a hydrophobic outside (semipermeable: permeable to gas but not to bacteria)
• Highly absorbent pads, sheets, or ropes which are available in many sizes

Answer 36

Foam Dressing

Question 37

80-99% water-or glycerin-based wound dressings that are available in sheets or amorphous gels

CANNOT be used on highly exudating and infected wounds; NOT appropriate for bleeding wounds

Answer 37

Hydrogel

Question 38

• Contain hydrophilic colloidal particles such as gelatin, pectin, and carboxymethylcellulose with a very strong film or foam adhesive backing
• Impermeable to water, oxygen and bacteria
• For woundswith minimal drainage
• Provides moist wound bed

NOT used on infected wounds
NOT appropriate for managing bleeding wounds or heavily draining wounds
NOT used on wounds with exposed tendon or fascia to avoid dessication of these structures

Answer 38

Hydrocolloid

Question 39

• Salts of alginic acid extracted from certain types of brown seaweed converted into calcium/sodium salts
• Have a soft, cotton-like appearance and can be either woven or nonwoven

NOT indicated for dry or minimally draining wounds, or in wounds with thick, black eschar

Answer 39

Alginates/Calcium Alginates

Question 40

Hydroactivedressings which are designed to have a selective absorptive capacity

EXPENSIVE

Answer 40

Hydrofiber